Edward Herman and Noam Chomsky’s book title Manufacturing Consent derives from presidential advisor and journalist Walter Lippmann’s phrase “the manufacture of consent”—a necessity for Lippmann, who believed that the general public is incompetent in discerning what’s truly best for them, and so their opinion must be molded by a benevolent elite who does know what’s best for them.

Starting in the 1990s—despite research findings that levels of the neurotransmitter serotonin were unrelated to depression—Americans began to be exposed to highly effective television commercials for antidepressants that portrayed depression as caused by a “chemical imbalance” of low levels of serotonin and which could be treated with “chemically balancing” antidepressants such as Prozac, Zoloft, Paxil, and other selective serotonin reuptake inhibitors (SSRIs).

Why has the American public not heard psychiatrists in positions of influence on the mass media debunking the chemical imbalance theory? Big Pharma’s corruption of psychiatry is only part of the explanation. Many psychiatrists, acting in the manner of a benevolent elite, did not alert the general public because they believed that the chemical imbalance theory was a useful fiction to get patients to accept their mental illness and take their medication. In other words, the chemical imbalance theory was an excellent way to manufacture consent.

In January 2012, National Public Radio correspondent Alix Spiegel began her piece with the following personal story about being prescribed Prozac when she was a teenager:

When I was 17 years old, I got so depressed that what felt like an enormous black hole appeared in my chest. Everywhere I went, the black hole went too. So to address the black-hole issue, my parents took me to a psychiatrist at Johns Hopkins Hospital. She did an evaluation and then told me this story: “The problem with you, she explained, “is that you have a chemical imbalance. It’s biological, just like diabetes, but it’s in your brain. This chemical in your brain called serotonin is too, too low. There’s not enough of it, and that’s what’s causing the chemical imbalance. We need to give you medication to correct that.” Then she handed my mother a prescription for Prozac.

This chemical imbalance story, countlessly repeated on antidepressant commercials and by psychiatrists from prestigious institutions, has been so effective that it comes as a surprise to many Americans—including Alix Spiegel— to discover that the psychiatric establishment now claims that it has always known that this theory was not true or “urban legend,” the term used by Ronald Pies, Editor-in-Chief Emeritus of the Psychiatric Times. Pies stated in 2011, “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.”

Truly well-informed psychiatrists have long known that research showed that low serotonin (or other neurotransmitter) levels were not the cause of depression. The American Medical AssociationEssential Guide to Depression in 1998 stated: “The link between low levels of serotonin and depressive illness is unclear, as some depressed people have too much serotonin.” But the vast majority of Americans—who didn’t read this textbook—never heard this.

In the 1990s, Pedro Delgado (the current chair of the psychiatry department at University of Texas) published research that showed if nondepressed people are depleted of serotonin, they will not become depressed. Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan, in Blaming the Brain (1998) detailed research that showed it is just as likely for people with normal serotonin levels to feel depressed as it is for people with abnormal serotonin levels, and that it is just as likely for people with abnormally high serotonin levels to feel depressed as it is for people with abnormally low serotonin levels. Valenstein concluded, “Furthermore, there is no convincing evidence that depressed people have a serotonin or norepinephrine deficiency.” But how many Americans heard about this?

Editor-in-Chief Emeritus of the Psychiatric Times Ronald Pies, a staunch defender of psychiatry and the American Psychiatric Association, believes that the APA fulfilled its obligation to inform the general public of the truth with a 2005 statement for the general public about depression that begins: “The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers.” But how many Americans read APA statements? And even if they had read that statement, they would not necessarily have come to the conclusion that the chemical imbalance theory was fiction and that drug commercials were deceptive. Even Pies admitted on April 15, 2014, “But still, shouldn’t psychiatrists in positions of influence have made greater efforts to knock down the chemical imbalance hypothesis, and to present a more sophisticated understanding of mental illness to the general public? Probably so.”

Thomas Insel, director of the National Institute of Mental Health (NIMH), in recent years has been increasingly critical of some of psychiatry’s theories and practices. In a February 25, 2007 interview with Newsweek, Insel did more explicitly tell the American people the truth that depression is not caused by low levels of the neurotransmitters serotonin or norepinephrine. However, he did not proclaim that drug commercials’ depiction of the cause of depression as patently false.

Given the drug commercial propaganda onslaught, for the American people to become aware of the truth, psychiatrists in positions of influence would have had to zealously publicize that the research had rejected the chemical imbalance theory, and they would have had to use the mass media to proclaim that the drug commercials are false. That never occurred. Why? NPR correspondent Alix Spiegel, as part of her January 2012 story, also interviewed several well-informed psychiatrists in positions of influence, and we get a clue as to the reason.

Alan Frazer, professor of pharmacology and psychiatry and chairman of the pharmacology department at the University of Texas Health Sciences Center, told NPR that by framing depression as a deficiency—something that needed to be returned to normal—patients felt more comfortable taking antidepressants. Frazer told NPR, “If there was this biological reason for them being depressed, some deficiency that the drug was correcting, then taking a drug was OK.” For Frazer, the story that depressed people have a chemical imbalance and that the antidepressant is correcting that imbalance is a story that has enabled many people to come out of the closet about being depressed.

And even Pedro Delgado, whose research helped debunk the serotonin deficiency theory of depression, agreed with Frazer that the fiction of the chemical imbalance theory has benefits. Delgado pointed to research showing that uncertainty itself can be harmful to people; and so simple and clear explanations, regardless of how inaccurate, can for Delgado be more helpful than complex truthful explanations.

Prior to the chemical imbalance campaign, many Americans were reluctant to take antidepressants—or to give them to their children. But the idea that depression is caused by a chemical imbalance which can be corrected with SSRI antidepressants sounded like taking insulin for diabetes. Correcting a chemical imbalance seemed like a reasonable thing to do, and so the use of SSRI antidepressants skyrocketed.

The U.S. Centers for Disease Control and Prevention (CDC) reported in 2011 that antidepressant use in the United States increased nearly 400 percent between 1988 and 2008, making antidepressants the most frequently used class of medications by Americans ages 18-44. By 2008, among Americans 12 years and older, 11 percent were taking antidepressants, and 23 percent of women ages 40–59 were taking them.

SSRIs skyrocketed despite the research which showed that SSRIs such as Prozac, Paxil, and Zolfot were not any more effective in reducing depression than the older tricyclic antidepressants such as Elavil. While for some antidepressant users, SSRIs had fewer adverse effects than the tricyclics, for many others, the adverse effects were just different and sometimes even worse (for example, the Food and Drug Administration forced SSRI manufactures to label SSRIs with “black box warnings” stating that SSRIs caused increased suicidality for patients under the age of 25). While SSRIs are neither more effective nor safer than the older tricylics, what is different was that tricyclics were never been marketed as correcting a chemical brain imbalance.

The chemical imbalance theory of mental illness has made Big Pharma billions of dollars by making it easier to sell SSRIs and other psychiatric drugs, and Big Pharma spread some of that money around to their favorite psychiatrists. And some well-informed psychiatrists in position of influence, not on Big Pharma’s payroll, have maintained the biochemical imbalance theory of mental illness to manufacture consent, because these psychiatrists have believed that it was in their patients’ best interest—making it easier for them to accept their depression and take their medication.

10 Responses

While I may agree we physicians may be a little quick to prescribe antidepressants, 80% of those I’ve prescribed them to and probably 90% of their family members are thankful after seeing the therapeutic response. Numbers like that are hard to argue with. pwmd

I was prescribed SSRIs when I was suffering from major depression that left me unable to hold full-time employment and unable to help myself due to incredibly low self-esteem. I was also in long-term therapy, and that was where I learned to see and work my way out of my difficulties. I have no doubt that SSRIs helped me get on my feet so that I was able to understand my situation and work through it. Like many of your readers, I know how to think for myself, and I do not let people in positions of authority interpret me or my life without question.

I have been to both good therapists and bad ones, and I don’t believe the issue is nearly as black-and-white as you present it. To begin with, there is also research that supports the efficacy of psychotropic medications. From my understanding, a relationship has been found between seratonin levels and mental/emotional states, but the causality is still in question. There may be a reciprocal relationship between the two, and there are likely other variables that account for individual differences in response to the drugs.

I do think that the media and “the powers that be” routinely place blame on individual shortcomings when cultural and societal problems also play a huge role in people’s lives. But, just as many psychiatrists and other physicians hand out drugs as if they are a panacea, I think you capitalize on the anger of people who understand the mechanizations of failing institutions, and the ultimate effect of your position may be to further the polarization of thought that is so rampant in contemporary discourse.

Like psychiatrists and Big Pharma, there are plenty of researchers who have agendas. Most of them do not work in clinical settings, and their research is based on what many professionals in the field consider questionable definitions of “improvement.” They are also funded by powerful institutions that are known to favor certain outcomes over others.

Nothing in this article or anything else that I’ve ever written discounts that many people swear by their antidepressants — as do many people swear by a variety of other approaches. This article was specifically about the chemical imbalance theory, which had been disproven by the research — as establishment psychiatry now admits — but which had been used to convince people to use antidepressants — Bruce

My decade of experience with several antidepressants is they are (at best) as much trouble as they’re worth. Yes, for someone in a rough state they may help stabilize but, to be fair, so can many other things that don’t offer a full slate of side effects at an often-substantial expense. I never believed or accepted the chemical imbalance theory, but soldiered on in pursuit of health. Eventually, that required that I ditch prescriptions in favor of St. John’s Wort (as documented by multiple studies in Germany and Switzerland), a better diet, and regular exercise.

Apart from the shoddy science behind both the chemical imbalance theory and prescription antidepressants in general, that still leaves America with the serious question of why there are so many people in distress. For my part, as a political science major and omnivorous reader, were we able to factor out the impacts of poverty and gross inequality, which most certainly track with higher rates of illness, then we could evaluate the strategy of blizzards of prescriptions written for decades. But that’s not yet where we are. As Naomi Klein noted in The Shock Doctrine (IIRC), in the wake of neoliberal assault on the newly-freed Baltic States, prescription meds were the highest-value import. It’s not a difficult equation to follow.

Until science provides much better evidence for genetic or chemical theories of mental illness, and possibly solutions, we are left with the obvious: improvements in quality of life for those in difficulty. Of course, this is a very tall order in America, and likely will be for some time to come. Meanwhile, ponder the treatment strategy used on wildlife caught in an oil spill: they’re cleaned up, nursed back to health, and released into a suitably healthy environment away from the disaster. Those contending with mental illness should be that lucky.

Great article, Bruce…thank you. I read it quite a while ago, actually. I sent a copy of it to my doctor (general practitioner, family doctor) as part of my effort to have a dialogue with him about psych meds in general, and in his response he stated that the serotonin theory of depression has not and could not be disproven because blood serum levels of serotonin may not be an accurate indication of serotonin levels in the brain. He also cited the oft-repeated argument (mentioned by the first respondent to your article, Paul Wichman) that in his experience “they work” (not for all, though, he admitted).

It seems there are a lot of factors contributing to depression – from thyroid, to vitamin levels, to food sensitivities and gut inflammation. So is it not possible that low serotonin may also be a contributing factor for some as well? Just because low serotonin is not always correlated with depression doesn’t mean it isn’t a factor for a select group.

It’s like saying not all depressed people have low B12 levels, so low B12 can’t possibly be a factor in depression – when we know it is.

Depression is complicated and multi-faceted. Let’s not throw the baby out with the bath water. Perhaps chemical imbalances do play a role for some people – but that it is not the only contributing factor. Perhaps this is why some people get better on antidepressants and some do not.

Depression is complicated. There are numerous factors. Thyroid, lifestyle, vitamin deficiencies, gut inflammation, toxic burden, etc. all play a factor. So is it not possible that low serotonin might be a factor as well?

You state that low serotonin is not always associated with depression. But does that mean it isn’t a factor for some?

That’s like saying that, since all depressed people don’t have low B12 levels, B12 isn’t a contributing factor.

Depression is multi-faceted. Perhaps we shouldn’t throw the baby out with the bath water. Maybe, for some people, low serotonin does play a factor in depression – and perhaps that is the reason that some people get better on SSRIs.